NCC221718_FRO Submitted_20220503

Town of Huntersville
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c� Soil Erosion &Sedimentation Control Ordinance
NORTH CARMIN,N Financial Responsibility/Ownership Form
No person shall initiate any land -disturbing activity as defined in the Town of Huntersville Soil
Erosion and Sedimentation Control Ordinance prior to completing and filing this form with the Town
of Huntersville. The financially responsible party will be on record as the party to receive any
Notices of Violation or related documents related to non-compliance issues with the above
Ordinance. By filing this form, the parties are not relieved from any other permits that may be
required for the Project. If the financially responsible party is out of State, a North Carolina agent
must be assigned.
Please Type or Print
PART A
1. Project where land -disturbing activity is to be undertaken: Gilead and Boren Commercial Site Plan
2. Address of land -disturbing activity: 14221 Boren Street, Huntersville NC 28078
3. Approximate date land -disturbing activity will commence: May 1 2022
Month Day Year
4. Purpose of development (Residential, Commercial, Industrial, etc.): Commercial
5. Approximate acreage of land to be disturbed or uncovered: 0.94 acres
6. Total site acreage: 1.406 acres
7. Landowners of record (use blank pages to list additional owners as necessary)
Owner #1 Name: Woodhaven Huntersville, LLC
Address: 6000 Fairview Rd, Ste 1530 Charlotte NC 28210
Telephone: [phone] _ Fax:
Email Address: [e-mail]
Owner #2 Name:
Address:
Telephone: _
Email Address:
Fax:
8. Indicate Book and Page where the deed or instrument is filed (use blank pages to list
additional deeds or instruments as necessary)
Book 36349 Page 403
Book Page
11/19
Book Page
Book Page

Financial Responsibility/Ownership Form - Continued
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity:
Persons or Firm: Woodhaven Development Group, LLC
Address: 6000 Fairview Rd Ste 1530 Charlotte NC 28210
Telephone: [phone]
Email Address: zackCa.woodhavendg.com
Fax:
2. North Carolina agent for the person or firm who is financially responsible:
Person or Firm:
Address:
Telephone:
Email Address:
Fax:
3. The above information is true and correct to the best of my knowledge and belief and was
provided by me while under oath. (This form must be signed by the financially responsible
person is an individual or by an officer, director, partner, attorney -in -fact, or other person
with authority to execute instruments for the financially responsible company or entity, if not
an individual)
Zack Kosofsky
Printed Name
Sign
I
Managing Member
Title
4/7/22
Date
a Notary
Public of theCounty of U CAge State of �j o r+ f two (1ncA.. , hereby
certify that
before me on this day and under oath a
Witness my hand and notarial seal, this
Notary Signature:
My Commission Expires:
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personally appeared
ed that this form was executed by him/her.
* day of IqR, rr I , 20 22
Town of Huntersville
PO Box 664
105 Gilead Rd., Ste 300
Huntersville, NC 28070